Massive bleeding from a ruptured metastatic hepatic melanoma treated by hepatic lobectomy. Case report and review of the literature.

An unusual case is reported of an occult, spontaneously rupturing, hemorrhagic, metastatic melanoma of the liver treated by hepatic lobectomy, resulting in short-term survival. A long, symptom-free interval (13 years) after excision of the primary cutaneous lesion (stage I) preceded the appearance of the hepatic metastasis. This case illustrates the need for a careful and thorough history as well as the benefit of prompt hepatic resection for bleeding from ruptured hepatic malignancies.

Ligation procedures in the management of portal hypertension.

In the 10 year period from 1964 through 1973, 25 patients bleeding from esophageal varices underwent ligation procedures coupled with splenectomy rather than a shunt. These procedures included the transesophageal and transgastric approaches and extragastric ligations. For patients with normal liver function, the risk of this urgent or emergency surgery is comparatively low (two of 12 patients died). The chance of recurrent hemorrhage is high (nine of nine surviving patients), as is the need for subsequent surgery (eight of nine patients). Nevertheless, despite these drawbacks, nine of these 12 patients (75 percent) are alive, and seven have survived 5 or more years. In patients with cirrhosis, the initial operative mortality rate (three of 12 patients) and the subsequent mortality rate (five additional patients) reflect the greater risk because of liver disease. Only five of 13 patients (38 percent) survive, three of whom are alive 5 or more years. In patients with cirrhosis, the initial operative mortality rate (three of 12 patients) and the subsequent mortality rate (five additional patients) reflect the greater risk because of liver disease. Only five of 13 patients (38 percent) survive, three of whom are alive 5 or more years after their initial surgery. These results indicate that there are situations when ligation procedures are valuable, especially in the noncirrhotic patient.

Pancreatoduodenal resection and total pnacreatectomy--an institutional review.

Between 1940 and 1978, 150 major pancreatic resections--92 pancreatoduodenal resections (PDRs) and 58 total pancreatectomies (TPs)--were performed for benign and malignant disease. The majority of resections were for pancreatic cancer (70 patients) and ampullary cancer (40 patients). The overall operative mortality rate for PDR was 14%; it was 26% for TP. After resection for adenocarcinoma of the head of the pancreas, the operative mortality rate was 28% for TP and 15% for PDR. The number of 5-year survivors after resection for cancer of the head of the pancreas was four (5.7%). Three survived after PDR and one after TP. Of the 42 adenocarcinomas resected by TP, one of the patients had multicentric cancer and two others had carcinoma in situ. TP appears to have no advantage over PDR for cancers of the head of the pancreas from a theoretical or practical standpoint.

Results of surgical treatment of periampullary tumors: a thirty-five-year experience.

Data on 126 consecutive patients with periampullary tumors resected at the Cleveland Clinic between January 1950 and December 1984 were reviewed. One hundred five patients underwent pancreatoduodenal resection, 10 patients total pancreatectomy, and 11 patients local resection of the tumor. The site of tumor was ampulla of Vater (59), head of the pancreas (30), duodenum (20), and distal common bile duct (11). Six patients had benign disease. The operative mortality rate for radical resection for the entire period was 7.8%; it has declined to 5.4% since 1974. The operative mortality rate for local resection was 9.1% (one patient). The overall 5-year survival rate for all malignant tumors of the periampullary area was 28% and 25.5% for invasive adenocarcinoma. Survival was affected primarily by location and histologic findings. The 5-year survival rate for adenocarcinoma of the ampulla of Vater was 37.2%, 27.5% for the duodenum, 16.7% for the distal common bile, and 4.3% for the pancreas (p = 0.0001). Papillary adenocarcinoma had a 5-year survival rate of 49.2% in contrast to 18.4% for nonpapillary ductal adenocarcinoma (p = 0.002). Patients with ampullary adenocarcinoma treated by local resection had a 5-year survival rate of 40.9%. These data justify continued use of a selective radical approach in the resection of most periampullary tumors with local resection for small tumors in high-risk patients.

Failure of LeVeen shunting in refractory ascites--a view from the other side.

We have reviewed our experience with 11 patients treated with LeVeen peritoneovenous shunts during a 22-month period from March, 1976, through December, 1977, to assess long-term results and shunt patency. Nine patients had follow-up studies to assess shunt patency at a mean of 26 months. After insertion of the shunt, the mean weight loss was 7.9 kg at hospital discharge. At 26-month follow-up evaluation, six patients had minimal ascites (responders), whereas five had massive ascites (nonresponders). Of the six responders, three patients with nonfunctioning shunts lost an average of 15.8 kg of ascites, three whereas with patent shunts lost an average of 15.0 kg. Eight of 11 patients (73%) required revision or replacement of the shunt because of malfunction; clotting was the most common cause of failure. We conclude that the role and effectiveness of LeVeen peritoneovenous shunts remain questionable. They may cause diuresis, maintain it, or not be responsible for it all. Clinical reports that cite their effectiveness should document patency of these shunts.

Transhepatic variceal sclerotherapy.

We attempted to control variceal hemorrhage, using transhepatic variceal sclerotherapy of a coronary varix. The procedure transiently controlled hemorrhage, but bleeding resumed from short gastric varices hours later.

Thrombosis in a cavernous left-sided inferior vena cava. An unusual abdominal mass.

A 19-year-old man had an abdominal mass and swelling of the left thigh. The presumptive diagnosis was lymphoma. On exploration the mass proved to be a thrombosed multiloculated "cavernous transformation" of a venous structure, presumably the inferior vena cava, which on postoperative cavogram was shown to be otherwise absent. The venous system of the left lower extremity showed phlebographic evidence of old thrombosis, but that of the right lower extremity was normal. The patient did well without further treatment, despite some residual swelling of the left thigh. To our knowledge, this precise combination of inferior vena cava anomalies has not been encountered before; certainly not presenting as a mass.

Safety, efficacy, and cost of pancreaticoduodenal resection in a specialized center based at a community hospital.

OBJECTIVE: To determine whether pancreaticoduodenal resection (PDR) for benign and malignant disease can be performed safely, efficiently, and economically at a 50-bed community hospital. DESIGN: Retrospective review of 39 consecutive PDRs performed in an 18-month period. Indications for surgery, length of hospital stay, complications, and patient charges were analyzed. SETTING: A suburban 50-bed community hospital. PATIENTS: Thirty-nine patients (15 male and 24 female) referred for PDR for benign and malignant disease. MAIN OUTCOME MEASURES: Mortality and morbidity rates, length of hospital stay, care, and cost. RESULTS: Of 39 patients who underwent PDRs, 1 patient (2.6%) died of myocardial infarct. Intraoperative blood transfusions were required by 3 patients (8%). The mean postoperative hospital stay was 11 days. Twenty-four patients (62%) were discharged by day 11. Fifteen patients (38%) were hospitalized 11 to 24 days. Complications in 10 patients (28%) included pancreatic or biliary fistula (n = 6), upper gastrointestinal tract bleeding (n = 1), partial wound dehiscence (n = 1), bacteremia (n = 1), and pneumonia (n = 1). No patient required reoperation. Three patients were rehospitalized within 1 month. Mean patient charges were $21,864, and mean reimbursements were $19,669. CONCLUSIONS: Pancreaticoduodenal resection can be accomplished with low morbidity and mortality rates and a short stay at a community hospital. Thorough preoperative investigations to exclude unresectable lesions must precede every PDR for malignant disease. Mortality and morbidity rates in this series were similar to those for patients with similar diagnoses who were operated on in academic centers. Cost for and length of hospital stay of these 39 patients were significantly lower than those in other reported series.

Results of conservative operations for breast cancer.

The results of conservative operations for breast cancer in 1,593 patients treated at the Cleveland Clinic between 1957 through 1975 are reported. During this period, we individualized our treatment of breast cancer depending on tumor size, location in the breast, and clinical stage of the disease. The following three principal operations were performed: modified radical mastectomy in 592 patients (37%), simple (total) mastectomy in 442 patients (28%), and partial (segmental) mastectomy in 291 patients (18%). Survival results at 5, 10, and 15 years are reported. Factors important in long-term survival included stage of the disease, number of lymph node metastases, delay in therapy, size of the tumor, histologic type, and estrogen receptor status; type of operation was not a significant factor. In this series, partial (segmental) mastectomy without radiation therapy provided five- to 15-year survival rates equal to modified radical mastectomy and simple (total) mastectomy.

Use of transcutaneous electrical stimulation in the control of postoperative pain.

Perception and relief of pain were studied in a varied group of fifty patients who had undergone laparotomy with upper abdominal midline incisions. Twenty-six patients were supplied with functioning transcutaneous electrical stimulators. Twenty-four received nonfunctioning machines. The controls were randomized by a nurse not otherwise involved in this study. Only seventeen of the total study group were judged failures and six of the patients had been receiving preoperative narcotics. Patient response was very favorable and pain relief was good to excellent, especially in one group with working stimulators (p is less than 0.008). Patients with known malignant disease did not respond as well as those with benign disease although anxiety may have been an important factor here. Use of the transcutaneous electrical stimulator would seem particularly worthwhile for patients undergoing elective abdominal operations for benign disease with no history of narcotic usage. Briefing the patient preoperatively on the potential value of transcutaneous electrical stimulation as a method of pain relief may improve end-results.

Computed tomography: a valuable aid to the abdominal surgeon.

The application of computed tomography (CT) for diseases of the liver, pancreas, kidney, and retroperitoneum has been described. The diagnostic accuracy of CT when compared with angiography, radioisotope scanning, endoscopic pancreatography, and transhepatic cholangiography is now being studied prospectively. The attractive features of CT include low risk, wide applicability, noninvasive technics, high diagnostic accuracy, and patient acceptance.

Surgical management of portal hypertension and esophageal varices. 10 year experience.

The results of 157 operations performed for portal hypertension and esophageal varices on 148 patients at the Cleveland Clinic in the 10 year period between 1970 and 1980 are reported. One hundred four shunt procedures and 53 ligation procedures were performed. The overall operative mortality rate of 13 percent did not differ significantly from the 11 percent rate reported from this institution in 1971. A comparatively higher rate of recurrent variceal hemorrhage and a lower rate of encephalopathy reflected our increased use of selective shunts and ligation procedures. There was no improvement in overall long-term survival, which was approximately 50 percent. The two most important factors in predicting the results of all operations for esophageal varices continue to be assessment of preoperative liver function and the timing of the operation. The best results were obtained in patients with good liver function who had an elective operation. Our data suggest that the portacaval shunt is associated with a higher incidence of late mortality, largely as a result of liver failure; therefore, our preference now is to perform a distal selective splenorenal shunt procedure whenever possible. If a selective shunt procedure cannot be performed, we advocate either a mesocaval shunt or a ligation procedure, depending on patient risk and the suitability of veins for a shunt procedure.

Endoscopic pancreatography: its value in preoperative and postoperative assessment of pancreatic disease.

Examples of the use of endoscopic pancreatography in the preoperative evaluation and postoperative follow-up study of patients with pancreatic disease are presented and discussed. Six cases selected from a total experience of forty-eight patients have been summarized. The direct role of pancreatography in the management of these cases is cited. There is a small but definite risk to the procedure. With increased use of endoscopic pancreatography, it is hoped that earlier diagnoses of a variety of pancreatic diseases will be obtained which will permit more accurate medical and surgical therapy.

Pancreatic cancer: the bigger picture.

Despite accurate diagnosis, better radiologic techniques, and safer surgery, long-term survival after surgical therapy for pancreatic cancer is disappointing. Median survival following pancreaticoduodenal resection is 12 to 15 months independent of surgical expertise, hospital size, or technical factors. Subsets of favorable tumors and longer survival times after surgery have been defined and include: small tumor size and low-grade lesions, tumor-free margins, and absence of nodal, venous, or perineural invasion; however, long-term survivors of pancreatic cancer may have none of these favorable features, and their tumors commonly manifest the most adverse tumor prognostic features. The converse that small-sized, histologically favorable tumors result in long-term survivors, also is not true. Five-year survival rates average 5% or less after all resections. In a large series in which 118 pancreatic resections were performed in 684 evaluated patients over a 6-year period, there were 12 5-year survivors, 5 of whom died in the sixth year. A report of 10-year survivors after surgery numbered 13 patients. The best actual 5-year survival rate was reported by Trede et al. Of the 37, 5-year survivors from a cohort of 118 patients, more than half died of cancer. This far exceeds any other actual survival rate and may be explained by a smaller tumor size. Farnell et al reported a 5-year survival rate difference (i.e., actuarial survival) in a subset of 174 resected patients with adenocarcinoma without perineural or duodenal invasion and with negative nodes (23% versus 6.8%), respectively. An impressive, large series of 616 patients with resected adenocarcinoma of the pancreas who underwent PDR (85%), distal pancreatectomy (9%), and total pancreatectomy (6%), has been reported. The mortality rate was 2.1%, and postoperative complications occurred in 30%. The five-year survival rate was 15%. The author's best result was observed among 20 initially "unresectable" patients who were treated with chemoradiation therapy, followed by tumor extirpation. Among the 18 surgical survivors there are seven five-year survivors, three of whom are in their tenth year of survival. They are discussed in the article by Cooperman et al ("Long-term Follow-up...") elsewhere in this issue.

An overview of pancreatic pseudocysts: the emperor's new clothes revisited.

The diminished role of surgery and increased role of nonoperative interventional therapy for pancreatic pseudocysts is discussed. The natural history supports prolonged observation for most asymptomatic pseudocysts.

Surgical treatment of pancreatic pseudocysts.

The surgical treatment of pancreatic pseudocysts (PC) has a less important role now that endoscopic and radiologic intervention can effectively treat PC. Surgery may be needed to correct the underlying cause--usually an obstructed or disrupted pancreatic duct.

Surgery and chronic pancreatitis.

It is hoped that, in this millennium, chronic pancreatitis will be diagnosed earlier in the course of the disease process. Improved axial imaging of the pancreatic duct and pancreatic parenchyma will diminish the need for other invasive tests. Surgical procedures are directed at pancreatic duct decompression or resection of the pancreas (head, body or tail) or, infrequently, total pancreatectomy. Pain relief in 75% to 90% is the general rule, with diabetes developing subsequently in as many as 33% of patients. Surgery for chronic pancreatitis is effective in correcting sequelae of pancreatic fibrosis. Endoscopic stenting of the pancreatic and bile duct is used more frequently today. Until their place is ascertained, careful performance of surgery will continue to be a mainstay of treatment.

Cancer of the pancreas: a dilemma in treatment.

The debate about what operation to perform for pancreatic cancer will, it is hoped, soon be ended. Individual philosophies will continue to dominate reason, but whatever one's philosophy or favorite operation, a critical look at surgeon's morbidity and mortality versus his or her patients' survival must dictate what will be done. The most optimistic five-year survival rate dose not exceed 5 per cent, and I believe the mortality must be lower than this. I suspect that disappointments with total pancreatectomy and more drastic operations will continue to be registered. As is the case with many neoplasms that, unfortunately, tend to be systemic, local measures are futile. Progress will be made by looking for better ways to extirpate these lesions and by an understanding of why there is an increase in pancreatic cancer.

Chronic pancreatitis.

Chronic pancreatitis is marked by recurrent bouts of pain, complications of pancreatitis, and progressive exocrine and endocrine dysfunction. Objective complications are generally well managed, although they do not alter the natural or progressive course of the disease. Treatment of palpable pseudocysts is varied, and the multiple surgical alternatives are equally effective, since most pancreas function until the pseudocyst decompresses. For patients with recurrent and/or persisting pain, selection of candidates is as important as selection of operations. The goal of preserving as much parenchyma as possible and doing decompressive procedures is attractive for this reason alone. Success, as measured by relief of pain and ability to return to work, is dependent upon cessation of abuse of alcohol and other drugs and perhaps progressive dysfunction of the pancreas.

Cancer of the ampulla of vater, bile duct, and duodenum.

The presenting features of periampullary cancer have been reviewed. Unless the neoplasm is discovered as an incidental finding at surgery, diagnosis is not made until the onset of symptoms (pain, jaundice, weight loss), which is not early, even though these tumors are close to the bile duct or ampulla of Vater. Individual philosophies aside, the prognosis for ampullary, duodenal, or distal bile duct tumors reflects the grade and stage of tumor as much as the operation done. Pancreatoduodenal resection, standard or modified, should be done with an attempt to cure and not to palliate. Statistics that show superior results after resection compared with palliative procedures reflect earlier stages lesions, healthier patients, and, most importantly, patient selection.